P36 A review of aspirin discharge documentation in paediatric cardiology

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Abstract

The humble drug Aspirin, derived from willow bark, is widely used in paediatric cardiology. It is used for a number of different indications mainly for its antiplatelet action; a few such examples include Blalock-Taussig shunts, Glenn shunts, post ablation stroke prevention and in Kawasaki Disease.

The discharge summary is a means of communicating changes to GPs, other hospitals and paediatricians within the paediatric cardiac network. The aim of the review was to assess the situation currently; whether the indication and duration of aspirin were documented on the patient’s discharge summary. This issue has been raised through our paediatric cardiac network meeting.

A retrospective study was carried out. A list of all patients discharged from the paediatric cardiac ward in January & February 2016 was obtained from Medway; our electronic patient information system for admissions and discharges. Using this list of patients, Heartsuite; our electronic cardiac database, was used to find 30 patients, who were discharged on aspirin.

The following data was collected on each of these discharge summaries; whether aspirin was newly started or continued, whether the indication and duration of aspirin was documented.

The data was collected and of the 30 discharge summaries viewed with aspirin on discharge; 18 (60%) were newly started on aspirin and 12 (40%) were continued on aspirin, 4 (13.3%) had the indication documented and 12 (40%) had the duration documented.

The paediatric cardiac patients discharged on aspirin, as shown by the results in this review show that the majority of discharge summaries do not have the indication or duration of aspirin documented. So, there was found to be inadequate documentation and communication to users in our paediatric cardiac network. With this in mind a service improvement is necessary.

The improvement suggestions are two-fold. Firstly, an additional note needs to be made to the surgical operation note that can be transferred to the discharge summary. Secondly, the addition of a mandatory field on the medication section of the discharge summary for the indication and the duration of aspirin.

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